Rx Drug Lookup

Rx Drug Lookup Form

Complete the below form and someone from our office will contact you as soon as possible.

First Name*

Last Name*

Email Address*

Phone Number*

ZIP Code*

What is your preferred pharmacy?

Are you open to having your prescriptions mailed to you, if it saves you additional money?

Yes

Medication 1

Drug Name

Dosage

Times Per Day

Medication 2

Drug Name

Dosage

Times Per Day

Medication 3

Drug Name

Dosage

Times Per Day

Medication 4

Drug Name

Dosage

Times Per Day

Medication 5

Drug Name

Dosage

Times Per Day

Medication 6

Drug Name

Dosage

Times Per Day

Medication 7

Drug Name

Dosage

Times Per Day

Medication 8

Drug Name

Dosage

Times Per Day

Medication 9

Drug Name

Dosage

Times Per Day

Medication 10

Drug Name

Dosage

Times Per Day

Provider 1

First Name

Last Name

Specialty

City

ZIP Code

Provider 2

First Name

Last Name

Specialty

City

ZIP Code

Provider 3

First Name

Last Name

Specialty

City

ZIP Code

Provider 4

First Name

Last Name

Specialty

City

ZIP Code

Provider 5

First Name

Last Name

Specialty

City

ZIP Code

Comments / Additional Drugs or Doctors

I am not a robot.

By completing this form you agree that a licensed insurance agent may contact you by phone or email to answer any questions you have regarding Medicare plans. This is a solicitation for insurance.

Anderson Insurance Services

59 E Queen Ave, Suite 100
Spokane, WA 99207

(509) 499-4116 or (406) 334-0373